Pain Management

KINGDOM OF SAUDI ARABIA ‫المملكـة العربيـة السعوديـة‬
MINISTRY OF HEALTH ‫وزارة الصحة‬

General Directorate of Health Affairs ‫المديرية العامة للشؤون الصحية‬
Makkah Al-Mukarramah Region ‫بمنطقة مكة المكرمة‬
AJYAD EMERGENCY HOSPITAL ‫مستشــفى أجياد للطوارئ‬
• It is allowed ONLY to access and keep this document with its owner and to whom it is
applicable.
• It is NOT allowed to photocopy – in part or as a whole, and if needed, request it from its
owner to have a copy.
TITLE: Pain management
1. DEFINITION:
1. Pain:
1.1. An unpleasant sensory and emotional experience associated with actual or potential tissue
damage or described in terms of such damage.
1.2. Pain is highly personal and subjective and is whatever the patient says it is, existing
whenever he/she says it does. Self-report of pain is considered the most reliable indicator of
pain.
1.3. Pain is often accompanied by emotional and spiritual responses, such as suffering or
anguish, and effective management should include measures to address these responses.
2. High Risk Pain Populations may include, but are not limited to:
2.1 Infants and children
2.2 Elderly, particularly over 70.
2.3 Women presenting with labor.
2.4 Patients who speak a different language or come from a different culture.
2.5 Patients with: a history of or active substance abuse; difficulty in communicating; limited
financial resources, social supports or access to health care; cognitive or psychosocial
impairments; metabolic alterations; analgesic allergies; and chronic
3. Acute Pain:
3.1 A normal, predicated physiologic response to an adverse clinical, thermal or mechanical

stimulus. It is generally time-limited and is responsive to opioid and non-opioid therapy.
Note: Acute pain episodes may be present in patients with chronic pain.
4. Chronic Pain :
Code MSD-PP-011 Issue No : 01 Issue Date: 01/05/1431 Activation Date:: 01/071431 Revision Date:: 30/04/1433 Copy No:
0 Page No: 1 / 8
applicable.
4.1 Malignant or non-malignant pain that exists beyond its expected time frame for healing or
where healing may not have occurred. It is persistent pain that is not amenable to routine pain
control methods.
Note: Patients with chronic pain may have episodes of acute pain related to treatment,
procedures, disease progression or reoccurrence.
5. Pain Management:
5.1 The use of pharmacological and non-pharmacological interventions to control the

patient’s identified pain. Pain management extends beyond pain relief, encompassing the
patient’s quality of life and ability to work productively, to enjoy recreation.
6. Pain Screen :
6.1 A quantitative rating of the intensity of pain reported by the patient utilizing a
standardized instrument that has demonstrated reliability and validity.
7. Pain Assessment:
7.1 An evaluation of the cause of the patient’s pain including but not limited to: location,
intensity, frequency, duration of pain, aggravating and relieving factors, effects on activities of
daily living, sleep patterns and psychosocial aspects of the patient’s life ,and effectiveness of
current strategies.
The pain assessment includes the rating from the pain screen, and all observed nonverbal
behavior
2. PURPOSE / INDICATION:
1. Maintaining an optimal level of comfort and safety for critically ill patients is our
universal goal and the gold-standard for the practice of analgesia and sedation.
2. Quality pain management begins with an affirmation by clinicians that patients

should have access to the best pain relief that can safely be provided.
3. CONTRAINDICATION: This policy and procedure (IPPs) is:

1. limited to prolonged sedation and analgesia
2. pertinent to patients older than 12 years
3. focused on the case of patients during mechanical ventilation and cases of acute coronary
syndrome.
0 Page No: 2 / 8
applicable.
4. POLICY:
• It is the policy of the hospital to evaluate, monitor and alleviate pain.

• The pain will be assessed as per the pain scale at the time of presentation in all cases and then will be
monitored with treatment for improvement.
• Those in pain will be assessed by the nursing staff on an hourly or 4 hourly basis as per need.
• All patients have a right to pain relief. (All critically ill patients have the right to adequate analgesia and
management of their pain).
5 MATERIALS AND EUQIPMENT: Not Applicable
6. PROCEDURE:
6.1. Assessment:
6.1.1 All patients are assessed for pain on admission, then subsequently thereafter according to
the initial assessment finding.
•
The registered nurse performs an initial screening and assessment, using the appropriate
Admission Assessment Form and pain measurement tool(s)
• The physician performs an initial pain assessment for pain factors, history and physical.
6.1.2. Pain Measurement Tools
6.1.2.1 General areas for Adult and Paediatric patients use the Pain Scale of 0-10. If they cannot
understand or are unwilling to use the scale, the Wong Baker FACES pain rating scale is used.
6.1.2.2Specialized areas use pain scales appropriate to the population and age group. For
example, the Neonatal/Infant Pain Scale (NIPS), and the Wong Baker FACES pain rating scale.
6.1.2.3 When patients are not able to give any from of self-report of pain for whatever reason;
e.g., pharmacological/physiological paralysis, developmental level, persistent vegetative state,
severe mental retardation, visual and hearing impairment, the Nonverbal Paediatric/Adult Pain
Scale is used.
6.1.3 When pain is identified, a comprehensive assessment is performed and documented. This
assessment is appropriate to the patient’s age and measures pain intensity and quality, such as:
• Pain character
0 Page No: 3 / 8
applicable.
• Frequency
• Onset
• Location
• Duration
6.2. Re-Assessment:
6.2.1 Reassessment occurs with each new report of pain, at a suitable interval following any pain
control intervention (particularly if a new medication or dosage is involved), and at regular
intervals appropriate to individual person status.
6.2.2 Acute/chronic pain will be reassessed within 1 hour depending on the medication and/or
alternative treatment administered.
6.2.3 The physician is notified when the pain score ≥ 4 indicating the prescribed pain
management regimen, is not effective.
6.3. Interventions:
6.3.1 Analgesic and treatments are administered as prescribed by physician order. Analgesics
ordered by physicians are administered via the least invasive route possible.
6.3.2 Nurses routinely, with vital signs, evaluate the patient for effective pain management, and
pain relief in accordance with the following guidelines:
• Oral analgesics – reassess in one hour;

IM – reassess in 30 minutes
IV – reassess in 15 minutes
6.3.3 Non-pharmacological interventions, if needed, are offered and taught to the patient:
• Heat/cold packs as prescribed.

• Repositioning, turning and/or ambulating as tolerated.
• Exercise, massage, immobilization, TENS
• Relaxation exercises i.e.: deep breathing, rhythmic breathing
• Distraction
6.3.4 The physician is notified for any ineffective management of pain when the pain score is ≥
4.
6.4. Age Related Considerations:

0 Page No: 4 / 8
applicable.
6.4.1 Geriatric:
• Drug metabolism is slower in the elderly due to decreased hepatic and renal function.
• At greater risk for drug-drug and drug-disease interactions due to multiple disease and
medications.
• Barriers to pain assessment include cognitive, visual, hearing and motor impairments.
• At risks for over and/or under treatment of analgesics:
a. NSAIDS increase the risk of renal toxicity.
b. Opioids have a higher peak and last longer leading to prolonged sedation and respiratory
depression.
6.4.2 Pediatrics:
• Assessment is required every 4-6 hours, with vital signs.

• Interventions for pain relief are reassessed with vital signs, in accordance with the
following guidelines:
a. Oral analgesics – reassess in one hour
b. IM – reassess in 30 minutes
c. IV – reassess in 15 minutes
• Emotional distress accentuates pain.

• Children in pain may regress.
• Observation of behavior and self-report are the primary methods for assessment.
6.5. Patient Education
6.5.1 Patient/family education begins after initial pain assessment with identified knowledge
deficit areas. When part of treatment, the patient/family is educated. About.
• Pain
• Other symptom
• All available and appropriate methods for managing pain and other symptoms.
6.5.2 The patient’s preference is considered in determining the method(s) used for pain
management.
6.5.3 The Interdisciplinary Patient/Family Education Record reflects the type of teaching
performed and the patient/family response.
0 Page No: 5 / 8
applicable.
6.5.4 The physician must be notified for multiple, different interventions that are not effective,
and/or patient/family does not demonstrate understanding and ability of education taught.
6.6. Staff Education
6.6.1 Staff who deliver direct patient care will receive education/training, regarding pain
assessment and management initially during new employee hospital orientation, and thereafter,
annually through mandatory hospital education.
6.7. Patient’ Rights
6.7.1 Patient’s rights include as assessment and appropriate management of pain. This right is addressed in the Patient
Handbook provided to each patient upon admission to the hospital.
6.8 Analgesia therapy:
a. A therapeutic plan and goal of anesthesia should be established for each patient and communicated to
all caregivers to ensure consistent analgesic therapy.
b. Nursing staff work together with the patient and other healthcare providers to establish a goal for pain
relief and develop and implement a plan to achieve that goal.
c. Non-pharmacologic interventions including attention to proper positioning of patients,
stabilization of fractures and elimination of irritating physical stimulation are important to maintain
patient comfort.
d. Pharmacologic therapies include:
6.12 Nonsteroidal anti-inflammatory drugs (NSAIDs)
Acetaminophen oral and Intravenous in a dose of maximum 4 gm over 24 hrs.

Diclofenac is one of the preferred drug at 1.5 mg/kg intrmuscular and oral routes as per severity.
6. 13. Opioids
a. If intravenous doses of an opioid analgesia are required, Fentanyl, Morphine
and Pethidine are the recommended agents.
b. Scheduled opioid doses or a continuous infusion is preferred over an “as
needed” regimen to ensure consistent analgesia. A patient-controlled analgesia (PCA)
device may be utilized to deliver opioids if the patient is able to understand and operated
the devices and if the device is available.
0 Page No: 6 / 8
applicable.
c. Fentanyl is preferred for a rapid onset of analgesia is acutely distressed patients
in a dose of 1 micro gm/kg upto 100 micro gm.
d. Fentanyl is preferred for patients with haemodynamic instability or renal
insufficiency.
e. Morphine is preferred for intermittent therapy because of their longer duration
of effect. It is the preferred drug for cardiac pain as in myocardial infarction. Doses
recommended are 0.1 mg/kg and pethidine at 1mg/kg.
f. NSAIDs may be used as adjuncts to opioids in selected patients.
g. NSAID may be used via the central route in appropriate patients.
h. Assessment of pain intensity may be performed with unidimensional tools,
such as VRS, VAS, and NRS. NPS is recommended to assess pain in critically ill
patients.
Numerical Pain Scale:
0 1 2 3 4 5 6 7 8 9 10
0-10, Zero equals no pain, 10 equals worst possible pain.
Categorical or Descriptive Pain Intensity Scale:
None Mild Moderate Severe Worst Possible
Visual Analog Scale:
No Pain Worst Possible Pain
The patient marks on the line the spot for the pain intensity, which is then measured. Non-written versions
can be used for very sick patients by having an attendant run a pencil along the line while the patient confirms
the point corresponding to the current pain.
Pain Relief Scale:
No Relief Complete Relief
0 Page No: 7 / 8
applicable.
Pain Affect Faces Scale:
  
1 2 3 4 5 6 7
7. REFERENCES:
1. World Health Organization Briefing Note-Access to Controlled Medications Programme. Geneva., World Health
Organization, 2007.
2. Achieving balance in national opioids control policy, Guidelines for assessment. Geneva, World Health Organization,
2000
3. Guidelines For WHO Guidelines: Global Programme on Evidence for Health Policy (EIP/GPE/EQC/2003.1), Geneva,
World Health Organization, 2003.
4. WHO model list of essential Drugs. Geneva, World Health Organization,2005
0 Page No: 8 / 8

Pain Management

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Pain Management

Uploaded by

Copyright:

Available Formats

KINGDOM OF SAUDI ARABIA ‫المملكـة العربيـة السعوديـة‬

MINISTRY OF HEALTH ‫وزارة الصحة‬

2.1 Infants and children

2.2 Elderly, particularly over 70.

2.3 Women presenting with labor.

3.1 A normal, predicated physiologic response to an adverse clinical, thermal or mechanical

5.1 The use of pharmacological and non-pharmacological interventions to control the

2. Quality pain management begins with an affirmation by clinicians that patients

3. CONTRAINDICATION: This policy and procedure (IPPs) is:

• It is the policy of the hospital to evaluate, monitor and alleviate pain.

5 MATERIALS AND EUQIPMENT: Not Applicable

• Oral analgesics – reassess in one hour;

• Heat/cold packs as prescribed.

6.4. Age Related Considerations:

• Assessment is required every 4-6 hours, with vital signs.

• Emotional distress accentuates pain.

6.5. Patient Education

6.6. Staff Education

6.7. Patient’ Rights

6.8 Analgesia therapy:

c. Non-pharmacologic interventions including attention to proper positioning of patients,

d. Pharmacologic therapies include:

6.12 Nonsteroidal anti-inflammatory drugs (NSAIDs)

Acetaminophen oral and Intravenous in a dose of maximum 4 gm over 24 hrs.

Numerical Pain Scale:

0-10, Zero equals no pain, 10 equals worst possible pain.

Categorical or Descriptive Pain Intensity Scale:

None Mild Moderate Severe Worst Possible

Visual Analog Scale:

No Pain Worst Possible Pain

Pain Relief Scale:

No Relief Complete Relief

4. WHO model list of essential Drugs. Geneva, World Health Organization,2005

You might also like